A Siniscalchi

University of Bologna, Bolonia, Emilia-Romagna, Italy

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Publications (72)232.53 Total impact


  • No preview · Article · Sep 2015
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    ABSTRACT: To evaluate the currently available evidence on thoracic epidural anesthesia effects on splanchnic macro and microcirculation, in physiologic and pathologic conditions. A PubMed search was conducted using the MeSH database. Anesthesia, Epidural was always the first MeSH heading and was combined by boolean operator AND with the following headings: Circulation, Splanchnic; Intestines; Pancreas and Pancreatitis; Liver Function Tests. EMBASE, Cochrane library, ClinicalTrials.gov and clinicaltrialsregister.eu were also searched using the same terms. Twenty-seven relevant studies and four ongoing trials were found. The data regarding the effects of epidural anesthesia on splanchnic perfusion are conflicting. The studies focusing on regional macro-hemodynamics in healthy animals and humans undergoing elective surgery, demonstrated no influence or worsening of regional perfusion in patients receiving thoracic epidural anesthesia (TEA). On the other hand most of the studies focusing on micro-hemodynamics, especially in pathologic low flow conditions, suggested that TEA could foster microcirculation. The available studies in this field are heterogeneous and the results conflicting, thus it is difficult to draw decisive conclusions. However there is increasing evidence deriving from animal studies, that thoracic epidural blockade could have an important role in modifying tissue microperfusion and protecting microcirculatory weak units from ischemic damage, regardless of the effects on macro-hemodynamics.
    Full-text · Article · Feb 2015
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    ABSTRACT: Introduction. Laparoscopic liver resection is considered risky in cirrhotic patients, even if minor surgical trauma of laparoscopy could be useful to prevent deterioration of a compromised liver function. This study aimed to identify the differences in terms of perioperative complications and early outcome in cirrhotic patients undergoing minor hepatic resection for hepatocellular carcinoma with open or laparoscopic technique. Methods. In this retrospective study, 156 cirrhotic patients undergoing liver resection for hepatocellular carcinoma were divided into two groups according to type of surgical approach: laparoscopy (LS group: 23 patients) or laparotomy (LT group: 133 patients). Perioperative data, mortality, and length of hospital stay were recorded. Results. Groups were matched for type of resection, median number of nodules, and median diameter of largest lesions. Groups were also homogeneous for preoperative liver and renal function tests. Intraoperative haemoglobin decrease and transfusions of red blood cells and fresh frozen plasma were significantly lower in LS group. MELD score lasted stable after laparoscopic resection, while it increased in laparotomic group. Postoperative liver and renal failure and mortality were all lower in LS group. Conclusions. Lower morbidity and mortality, maintenance of liver function, and shorter hospital stay suggest the safety and benefit of laparoscopic approach.
    Full-text · Article · Dec 2014 · HPB Surgery
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    ABSTRACT: The current case report describes a case of Intraoperative progressive hemodynamic failure in a patient undergoing orthotropic liver transplantation. Rescue transesophageal echocardiography was used to facilitate rapid diagnosis of a iatrogenic acute pericardial tamponade, resulting from a suture penetrating the pericardium through the right hemi diaphragm. This potentially lethal complication required an immediate echo-assisted pericardiocenthesis.
    Full-text · Article · Nov 2014
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    ABSTRACT: Introduction: Since cirrhotic patients undergoing hepatic resection are at increased risk of developing postoperative coagulopathy, epidural catheter placement in this group of patients is still debated. This retrospective study aimed to evaluate postoperative course of coagulation parameters after surgical hepatic resection in cirrhotic patients and their relation to extent of resection and perioperative risk factors. Methods: Perioperative data from 232 hepatic resections performed in cirrhotic patients were reviewed. We defined postoperative coagulopathy the occurrence of a postoperative platelet count < 100,000/ml and/or INR value = 1.5. Logistic regression was used to assess the association between postoperative coagulopathy and several potential risk factors, while general linear model for repeated measures was used to compare postoperative course of coagulation parameters. Results: 98 patients (42.24%) showed an abnormal coagulation profile at least once during the first 7 postoperative days. None of the analyzed parameters resulted statistically associated with the development of postoperative coagulopathy. Postoperative INR course was significantly different in patients undergoing minor resections with better values, while platelet count was not. Conclusions: Postoperative coagulopathy after hepatic resections is a common issue in cirrhotic patients, which may limit the feasibility of invasive procedures such as epidural catheter placement. Multivariate analysis didn't show any association between investigated risk factors and postoperative coagulopathy. Postoperative course of coagulation parameters in cirrhotic patients with normal preoperative coagulation tests undergoing minor liver resection seems to be compatible with epidural catheter placement and management.
    Full-text · Article · Oct 2014
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    ABSTRACT: Background Kidney function usually deteriorates after intestinal transplant, with prevalence of renal failure almost 20% after 5 years. We report our results on adults from single institution over >10 years. Methods Forty-six patients were transplanted with 22 survivors; we divided them in 2 groups: Group 1, recipients with creatinine >1.2 mg/dL (normal, 0.50–1.2) and Group 2, normal creatinine. Group 1 included 12 patients (9 males) with a mean age of 42.8 years; all lived at home, with normal creatinine at transplant (apart from 1 patient with a creatinine of 1.6 mg/dL), and were mainly transplanted for short bowel syndrome. One underwent retransplantation. Immunosuppression was based on alemtuzumab (8 recipients) plus tacrolimus (FK). Group 2 included 10 patients (6 males) with a mean age of 34.7 years; all lived at home, had normal creatinine at transplantation, and were mainly transplanted for short bowel syndrome. Immunosuppression was mainly based on alemtuzumab (8 recipients) plus FK. Results There were no relevant differences between the 2 groups regarding number of recipients, sex, baseline creatinine at transplant, reason for transplantation, retransplantation, immunosuppression, antifungal or antiviral therapy, hospitalization, total parenteral nutrition (or fluids), or stoma. The only relevant difference was age (P = .04); patients with deteriorated kidney function or altered creatinine were found to be older.
    No preview · Article · Sep 2014 · Transplantation Proceedings
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    Full-text · Conference Paper · Jun 2014
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    ABSTRACT: BACKGROUND Although previous studies have suggested the potential advantages of albumin administration in patients with severe sepsis, its efficacy has not been fully established. METHODS In this multicenter, open-label trial, we randomly assigned 1818 patients with severe sepsis, in 100 intensive care units (ICUs), to receive either 20% albumin and crystalloid solution or crystalloid solution alone. In the albumin group, the target serum albumin concentration was 30 g per liter or more until discharge from the ICU or 28 days after randomization. The primary outcome was death from any cause at 28 days. Secondary outcomes were death from any cause at 90 days, the number of patients with organ dysfunction and the degree of dysfunction, and length of stay in the ICU and the hospital. RESULTS During the first 7 days, patients in the albumin group, as compared with those in the crystalloid group, had a higher mean arterial pressure (P = 0.03) and lower net fluid balance (P<0.001). The total daily amount of administered fluid did not differ significantly between the two groups (P = 0.10). At 28 days, 285 of 895 patients (31.8%) in the albumin group and 288 of 900 (32.0%) in the crystalloid group had died (relative risk in the albumin group, 1.00; 95% confidence interval [CI], 0.87 to 1.14; P = 0.94). At 90 days, 365 of 888 patients (41.1%) in the albumin group and 389 of 893 (43.6%) in the crystalloid group had died (relative risk, 0.94; 95% CI, 0.85 to 1.05; P = 0.29). No significant differences in other secondary outcomes were observed between the two groups. CONCLUSIONS In patients with severe sepsis, albumin replacement in addition to crystalloids, as compared with crystalloids alone, did not improve the rate of survival at 28 and 90 days. (Funded by the Italian Medicines Agency; ALBIOS ClinicalTrials.gov number, NCT00707122.)
    Full-text · Article · Mar 2014 · New England Journal of Medicine
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    ABSTRACT: Background: The possibility of outlining a risk profile for perioperative blood transfusion of cirrhotic patients submitted to hepatic resection can help to rationalize transfusion policy. Methods: Data from 323 hepatic resections, performed in cirrhotic patients, were reviewed. Bootstrap and a leave-one-out logistic regressions were applied to test the accuracy of available risk scores for peri-operative transfusion identified from PubMed search of the last 20 years, to refine them, and to provide internal validation for present results. Results: One-hundred-six patients (32.8%) required blood transfusions during either intra- and/or postoperative. The predictive accuracy of three identified risk scores was poor with the area under receiver operating characteristics (AUROC) curves <0.70 in all cases. Tumor diameter, hemoglobin and presence of coronary artery disease were confirmed, in the present cohort, as predictors of blood transfusion together with serum albumin and bilirubin. The leave-one-out logistic regression results in an AUROC of 0.80, and of 0.79 for internal validation, significantly higher than that of the three scores tested (P<0.001). A Maximal Surgical Blood Order Schedule stratification was proposed. Conclusion: The risk profile for transfusion of cirrhotic patients undergoing hepatectomy can be better assessed with a model that combines already known clinical factors and hepatic function indexes.
    No preview · Article · Nov 2013 · Minerva anestesiologica
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    A Lauro · C Zanfi · A Bagni · M Cescon · A Siniscalchi · S Pellegrini · L Pironi · A D Pinna
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    ABSTRACT: The incidence of early rejection after intestinal transplantation correlates with heightened risk of graft loss and mortality. Many different induction or pre-conditioning protocols have been reported in the last 10 yr to improve outcomes; however, sepsis remains prevalent and diminishes long-term results. We recently began a "2-dose" alemtuzumab trial protocol - 15 mg at day 0 and 15 mg repeated on day 7 - with the hope of reducing our infection rate. We compared three different protocols used at our institution (daclizumab, conventional "4-dose" alemtuzumab, and "2-dose" alemtuzumab). There was a significantly lower rate of early rejection with the "2-dose" alemtuzumab protocol in our study group of mainly (88%) intestinal grafts without accompanying liver engraftment with its protective immunologic effect. Sepsis remained low. Longer follow-up will be required to evaluate the effects of this new protocol on longer-term outcomes.
    Full-text · Article · Jul 2013 · Clinical Transplantation
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    Full-text · Conference Paper · Jun 2013
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    ABSTRACT: Background: Liver cirrhosis is associated with a hyperdynamic circulation (HC). In this observational study, we aimed to investigate the predictive factors of HC, its impact on intraoperative hemodynamic and postoperative outcome, early ICU and in-hospital mortality, in cirrhotic patients undergoing orthotopic liver transplantation (OLT). Methods: Two hundred and forty-two patients with cirrhosis undergoing cadaveric OLT were included. Before starting the transplant procedure and under general anesthesia, a pulmonary artery catheter was introduced to assess hemodynamic parameters. The baseline assessment was carried out approximately 30 minutes after the catheter placement and repeated during the anhepatic phase, 10 minutes after the reperfusion and at the end of surgery. The patients were divided into two groups: in group 1 the patients had SVR>900dynes s-1 m-2 cm-5, in group 2 SVR ≤900 dynes s-1 m-2 cm-5. Results: Eighty-two patients (33%) presented severe HC. In multivariate analysis 2 factors were associated with the occurrence of HC: beta-blockers use (Exp [B]=4.42 (95% CI 1.18-17); P=0.001, [34% and 12% in groups 1 and 2, P<0.001, respectively]) and model for end-stage liver disease (MELD) score (Exp [B]=1.066; 95% CI=1.025-1.109; P=0.001). Conclusion: MELD score was an independent predictor of HC, and beta-blockers resulted associated with lower incidence of HC in cirrhotic patients undergoing cadaveric OLT. Intraoperative HC correlates with hemodynamic alterations, requiring more blood products and vasopressor use, this may increase the risk of renal failure, early ICU death and in-hospital mortality.
    No preview · Article · Oct 2012 · Minerva anestesiologica
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    Full-text · Conference Paper · Oct 2012
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    ABSTRACT: Slight alterations in cardiac enzymes are frequently observed perioperatively among liver transplant patients. The significance of these changes in the absence of ongoing acute cardiac pathology is unknown. We sought to evaluate the link between early postoperative anomalies of serum cardiac troponin T (cTnT) in the absence of an evident cardiac cause and kidney injury during the first week of hospital stay. We retrospectively enrolled 30 patients in the study, recording several perioperative variables, particularly cTnT on intensive care unit ICU arrival as well as 6 and 12 hours later. We grouped patients with cTnT levels >0.03 ng/mL as the high-TnT group; the others were control subjects. We recorded the highest serum creatinine, aspartate aminotransferase, alanine aminotransferase, and bilirubin levels during the first week of the hospital stay. Glomerular filtration rate (GFR) was calculated according to the Cockroft-Gault formula. Ten patients composed the high-TnT group. Their perioperative variables showed higher Model for End-Stage Liver Disease (MELD) scores and significantly greater incidences of acute kidney injury, failure, and dialysis need than control patients. GFR dropped from 118 to 66 mL/min among this group versus 112 to 105 mL/min in control subjects (P = .021). Binary logistic regression analysis revealed a higher association between the high-TnT group and acute kidney injury (P = .036) than with the MELD score (P = .719). Serum cTnT levels could be influenced by both preoperative and intraoperative conditions that predispose to kidney injury.
    No preview · Article · Sep 2012 · Transplantation Proceedings
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    Full-text · Conference Paper · Jun 2012
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    ABSTRACT: Stevens-Johnson syndrome (SJS) is a potentially deadly skin disease that usually results from a drug reaction. Typically, it involves the skin and mucous membranes. While minor presentations may occur, significant involvement of the oral, nasal, eye, vaginal, urethral, gastrointestinal (GI), and lower respiratory tract mucous membranes may develop in the course of the illness. GI and respiratory involvement may progress to necrosis. Missed diagnosis is common, and recovery can take weeks to months, depending on the severity of the condition [1]. We describe an SJS developed in a primary plasma cell leukaemia during Revlimid and dexamethasone (Rev/Dex) treatment. OnApril 2010, a 51-year-oldmanwas admitted toour centre for fever and worsening general conditions. Laboratory tests showed the following data: leukocytosis (WBC 20, 500/μl) with peripheral plasma cells >2, 000/μl, anaemia (HGB 10.3 g/dl), thrombocytopenia (PLTS 83000/μl), serumMprotein IgA-lambda (1.47 g/dl), urinary Bence-Jones protein positivity (lambda light chain 2.5 g/24 h), renal failure (creatinine 2.5 mg/dl), hyperuricemia (12.3 mg/dl), bone marrow monoclonal plasma cells CD138 +, CD19 ?, CD38 + and CD56 ? and multiple lytic bone lesions. A diagnosis of primary plasma cell leukaemia was made, and patient was enrolled in a multicentric Italian study including four 28-day cycles of Rev/Dex (lenalidomide 25 mg/day p.o. for 21 days and dexamethasone 40 mg/day p.o. days 1, 8, 15 and 22 of each cycle) as induction therapy of a transplant program. In addition, as supportive therapy, the patient was on co-trimoxazole, proton pump inhibitor and allopurinol treatment. On day +24 of the first cycle, the patient developed an erythematous maculopapular and mildly pruritic rash on the trunk, back, abdomen, upper and lower limbs. Prednisolone and antihistamines were introduced. On day +27, the patient experienced grade 2 orogenital mucositis and worsening of cutaneous rash, with the appearance of foot desquamation and ulceration areas (Fig. 1). A clinical diagnosis of Stevens-Johnson syndrome was made, excluding a diagnosis of toxic epidermal necrolysis (Table 1). No skin biopsy was performed. Patient was transferred to our transplant unit and received corticosteroids, high-dose intravenous immunoglobulin, prophylactic antibiotics and fluid input. He remained haemodynamically stable and did not develop multi-organ failure. Cutaneous rash and orogenital mucositis gradually improved. The patient is alive, waiting for the beginning of new treatment for his haematological disease.
    No preview · Article · May 2012 · Supportive Care in Cancer
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    ABSTRACT: Bisphosphonates (BPs) are used intravenously to treat cancer-related conditions for the prevention of pathological fractures. Osteonecrosis of the jaw (BRONJ) is a rare complication reported in 4-15% of patients. We studied, retrospectively, 55 patients with multiple myeloma or Waldenstrom's macroglobulinemia followed up from different haematological departments who developed BRONJ. All patients were treated with BPs for bone lesions and/or fractures. The most common trigger for BRONJ was dental alveolar surgery. After a median observation of 26 months, no death caused by BRONJ complication was reported. In all, 51 patients were treated with antibiotic therapy, and in 6 patients, this was performed in association with surgical debridement of necrotic bone, in 16 with hyperbaric O(2) therapy/ozonotherapy and curettage and in 12 with sequestrectomy and O(2)/hyperbaric therapy. Complete response was observed in 20 cases, partial response in 21, unchanged in 9 and worsening in 3. The association of surgical treatment with antibiotic therapy seems to be more effective in eradicating the necrotic bone than antibiotic treatment alone. O(2) hyperbaric/ozonotherapy is a very effective treatment. The cumulative dosage of BPs is important for the evolution of BRONJ. Because the most common trigger for BRONJ was dental extractions, all patients, before BP treatment, must achieve an optimal periodontal health.
    Preview · Article · Mar 2012 · Blood Cancer Journal

  • No preview · Article · Jan 2012 · Blood
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    ABSTRACT: Background: The risk of developing a tumor is 2.1% per year of life in the general population older than 65 years. In MGUS, the incidence of AML/MDS is increased 8 fold compared with normal population, this observation supports a role for non-treatment related factors in the causation of AML/MDS in plasma-cell dyscrasias (Blood, July 27,2011). In multiple myeloma (MM) patients, the risk of second primary malignancy (SPM) is influenced by age and the use of alkylating agents. Methods: We examined SPM incidence rates (IRs) per 100 person-years in 2459 newly diagnosed MM patients, enrolled in 9 experimental trials of the European Myeloma Network (RVMM EMN 01, RVMM EMN 441, RVMM PI 026, RVMM PI 302, RVMM PI 209, GIMEMA MM 03 05, GIMEMA MM 04 05, GISMM 2001, HOVON 87). 287 patients received cyclophosphamide-lenalidomide-corticosteroids (CRC), 685 melphalan-prednisone-lenalidomide (MPR), 484 high-dose melphalan followed by lenalidomide maintenance (MEL200-R), 164 melphalan-prednisone (MP), 328 MP-thalidomide (MPT), 257 MP-bortezomib (MPV), 254 MP-bortezomib-thalidomide (VMPT). This post hoc analysis was restricted on pooled data from 1798 patients with at least 1 year of follow-up. Results: As of March 2011 cut-off, median follow-up was 28 months. Median age was 69 years, 49% of patients were aged 65-74 years, and 19% aged ≥75 years. Total cases of SPMs were 30/1798 (IR 0.72), including 8 hematologic (acute leukemia) and 22 solid cancers (gastrointestinal, lung, breast, skin, gynecologic). No cases of SPMs were reported in patients receiving cyclophosphamide and lenalidomide. [Table Presented] SPM: second primary malignancy; CRC: cyclophosphamide-lenalidomide-corticosteroids; MPR: melphalan-prednisone-lenalidomide; MEL200-R: high-dose melphalan followed by lenalidomide maintenance; MP: melphalan-prednisone; MPT: MP-thalidomide; MPV: MP-bortezomib; VMPT: MP-bortezomib-thalidomide In patients receiving lenalidomide and alkylating agents (CRC/MPR/MEL200-R), the cumulative incidence of death for MM and diagnosis of SPMs at 3 years was 13.8% and 2.0%, respectively. In patients not receiving lenalidomide (MP/MPT/MPV/VMPT), the cumulative incidence of death and SPMs at 3 years was 26.1% and 1.1%, respectively. In the analysis restricted to Italian patients treated with lenalidomide and alkylating agents, we report 11 cases of SPMs. This figure is lower than the 15.6 cases expected from the age/sex adjusted incidence derived form the Italian Cancer Registry, with a standardized incidence ratio of 0.70. Conclusions: SPM incidence was lower than expected in all treatment groups. At present, the benefits of continuous therapy with lenalidomide outweigh the potential risk of SPMs. Longer follow-up is needed to definitively assess the risk of SPMs in patients receiving lenalidomide with alkylating agents. With the limitation of a short follow-up, the numbers currently support a role for non-treatment related factors as causes of SPMs. Updated data will be presented at the meeting.
    No preview · Conference Paper · Nov 2011
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    ABSTRACT: Post-reperfusion syndrome (PRS) during isolated intestinal transplantation (ITx) is characterized by decreased systemic blood pressure, systemic vascular resistance, and cardiac output and by a moderate increased pulmonary arterial pressure. We hypothesize that the more severe PRS causes a poorer long-term outcome. The primary aim of this study was to determine the independent clinical predictors of intra-operative PRS, as well as to investigate the link between the severity of PRS and the intra-operative profiles and to examine the post-operative complications and their relationship with transplant outcome. This observational study was conducted on 27 patients undergoing isolated ITx in a single adult liver and multivisceral transplantation center. PRS was considered when the mean arterial blood pressure was 30% lower than the pre-unclamping value and lasted for at least one min within 10 min after unclamping. The main results of this study can be summarized in two findings: in patients undergoing ITx, the duration of cold ischemia and the pre-operative glomerular filtration rate were independent predictors of PRS and the occurrence of intra-operative PRS was associated with significantly more frequent post-operative renal failure and early post-operative death.
    No preview · Article · Oct 2011 · Clinical Transplantation

Publication Stats

524 Citations
232.53 Total Impact Points

Institutions

  • 2005-2014
    • University of Bologna
      • Department of Experimental, Diagnostic and Specialty Medicine DIMES
      Bolonia, Emilia-Romagna, Italy
    • Università degli Studi di Siena
      Siena, Tuscany, Italy
  • 2012
    • Ospedale Nuovo Regina Margherita
      Roma, Latium, Italy
  • 2008-2012
    • University of Rome Tor Vergata
      • Dipartimento di Biopatologia e Diagnostica per Immagini
      Roma, Latium, Italy
  • 2006-2007
    • Policlinico S.Orsola-Malpighi
      Bolonia, Emilia-Romagna, Italy
  • 2000-2005
    • Università degli Studi di Modena e Reggio Emilia
      • • Department of Biomedical, Metabolical and Neurosciences
      • • Emergency department
      Modène, Emilia-Romagna, Italy